1. Endodontic flare-ups

2. Introduction
Pain may occur soon after initiating endodontic treatment for an asymptomatic tooth or shortly after the initial emergency
treatment or during the course of treatment.

3. Flare-up is described as the occurrence of pain, swelling or the combination of these during the course of root canal therapy, which results in unscheduled visits by patient.

4. American Association of Endodontics (AAE) defines a flare-up “as an acute exacerbation of periradicular pathosis after initiation or in continuation of root canal treatment.”

5. Flare-ups may occur with the best of the therapy, but most flare-ups occur when improper treatment is rendered or when insufficient time is allowed for specific modalities in therapy

6. ETIOLOGY Causative Factors
The occurrence of flare-ups during the endodontic therapy is a polyetiologic phenomenon.
Causative Factors
Comprise mechanical, chemical and/or microbial injury to the pulp or periapical tissues resulting in the release of myriad of inflammatory mediators. Pain then occurs due to the direct stimulation of the nerve fibers by these mediators or edema resulting in an increase in the hydrostatic pressure with consequent compression of nerve endings

7. Causative Factors A-Mechanical Injury 3-Overinstrumentation—
most common cause of mid treatment flare-ups.
1- Periapical extrusion of
debris
2-Incomplete removal of pulp tissue.

8. B-Chemical Injury Irrigants Intracanal medicaments
Overextended filling materials

9. C-Microbial Induced Injury
It is considered as the most significant factor in the flare-up pathogenesis. Microbial factors may be combined with iatrogenic factors to cause inter-appointment pain.

11. Contributing Factors for Flare-ups
Age ..Patients in the 40–59 years range have the most flare-ups and those under the age of 20 have the least.
Gender.. females < males .
Tooth type.. Mandibular teeth <maxillary teeth
molars< 17 times than other teeth.

12. Pulpal &Periradicular status.. vital pulps >necrotic pulp
3.4 % chronic apical periodontitis
4.8% acute apical periodontitis
13.1 % acute apical abscess.
Pre-operative pain.. 80% of patients who feel tooth pain before the beginning of the treatment usually feel the pain after treatment
Allergies.. higher frequency of inter-appointment pain
Anxiety.. Anxious patients are likely to have more pain during the course of the treatment
Number of Visits .. If proper case selection is not done, more flare-ups occur after multi-visit approach as compared to single visit approach to
endodontics.
Retreatment Cases… Chances of flare-ups are 10 folds higher in the retreatment cases because of extrusion of infected debris or solvents into
periapical tissues

13. Hypothesis for flare ups
Dr Seltzer discussed a number of hypothesis thought to be related to the etiology of flareups
Alteration of the local adaption syndrome .
Changes in periapical tissue pressure .
Microbial factors.
Effects of chemical mediators.
Changes in cyclic nucleotides.
Immunological phenomena.
Various psychological factors

14. 1 - Alteration of local adaptation syndrome
when a new irritant is introduced in a chronically inflamed tissue, a violent reaction may occur because of disturbance in local tissue adaptation to applied irritants. For example in case of chronic pulpal diseases, the inflammatory lesion is adapted to irritants but during root canal therapy, a new irritant in form of medicament get introduced in the lesion leading to flare-up

15. 2- Changes in Periapical Tissue Pressure
Studies have shown that endodontic therapy causes pressure changes in periapical area in both directions
Teeth with POSITIVE periapical pressure, excessive exudate creates pain by causing pressure on nerve endings. Root canals of such teeth when kept open, exudate comes out but in teeth with NEGATIVE periapical pressure, microorganisms and altered tissue proteins gets aspirated into periapical area leading to increased inflammatory response and pain.

16. 3- Microbial Factors
Gram-negative anaerobes Produce a variety of enzymes and release neurotoxic endotoxins. Also they activate the Hageman factor to release bradykinin, a potent pain mediator.
Teichoic acid, present in the cell wall and plasma membranes of many gram positive bacteria is potent immunogen, producing humoral antibodies IgM, IgG, IgA and releases various chemical, mediators that cause pain.

17. Microbial Mechanisms in the Induction of Flare-ups
1- Extrusion of microorganisms and their products result in flare-ups

18. 2- Incomplete debridement of canal disrupts the balance between various microbial communities with in root canal system and favor the overgrowth of certain species.

19. 3-Coronal leakage leads to Secondary intraradicular infection

20. 4- Alteration of oxidation-reduction potential in the root
canal during treatment may favor the overgrowth of
facultative bacteria that resisted chemomechanical
procedures and lead to flare-ups.

21. 4- Effects of chemical mediators
Cell mediators Like histamine, serotonin, prostaglandins, platelet activating factors, leukotrienes etc. are capable of producing severe pain, which are released from cells.

23. 5 -Changes in Cyclic Nucleotides
Increased levels of cAMP inhibits mast cell degranulation which helps in reducing pain where as increase in cGMP levels stimulate mast cell degranulation which results in increase in pain. Studies have shown that during
flare-up, there is increased
level of cGMP over
cAMP concentrations.

24. 6- Immunological Response
In chronic pulpitis and periapical disease, presence of macrophages and lymphocytes indicates both cell mediated and humoral response. Despite of their protective effect, the immunologic response also contributes to destructive phase of reaction which can occur, causing perpetuation and aggravation of inflammatory process.

25. 7- Psychological factors
Anxiety, fear, psychosis, apprehension & previous traumatic dental experience means a lot to dental patients especially during root canal procedures
These anxieties aggravate and intensify painful episodes

26. CLINICAL CONDITIONS RELATED
TO FLARE-UP
Flare-ups in endodontics may be grouped as:
Interappointment flare-ups.
Postobturation flare-ups.

27. 1- Interappointment flare-ups.
Apical periodontitis secondary to treatment:
An asymptomatic tooth become sensitive to percussion.
Pain may become severe causing a throbbing or gnawing pain.
Causes:
Over instrumentation.
Over medication.
Forcing debris into periapical tissue.

28. Confirmatory test: Use paper point Mark W/L.
Place the paper point in the canal.
If over instrumentation has happened by fault, then the paper point will go beyond the working length without obstruction. On withdrawal, tip of the point will show a reddish or brownish color indicating inflamed tissue in the periapical region and absence of stop in apical preparation.

29. Management:
An intracanal corticosteroid-antibiotic medication is given to the patient for symptomatic relief. The medication is carried on the paper point and applied with a pumping action so as to reach the inflammed periapical tissues.
Routine endodontic therapy may be continued after 2 to 5 days after readjusting the working length

30. Incomplete removal of pulp tissue:
Sensitivity to hot and cold or pain on percussion is usually seen.
Confirmatory test:
When paper point is removed, it will display
brownish discoloration and short of the
working length. indicative of
inflamed seeping tissue.
Management:
The working length is re-established and the
remaining pulp tissue is removed.

31. Recrudescence of chronic apical periodontitis: (phoenix abscess).
It is a condition that occurs in teeth with necrotic pulps and
apical lesions that are asymptomatic.
It occurs due to the alteration of the internal environment of root canal space during instrumentation which activates the bacterial flora.
Mobility, tenderness and swelling are usually the sign and symptoms.

32. Management: The tooth is opened under rubber dam and
allowed to drain. Irrigation with warm sterile saline or water helps to encourage the drainage.
Drainage is allowed until the exudation ceases or a slight clear serum drains. The canal is then irrigated with sodium hypochlorite, dried with paper point; filled with an appropriate intracanal medicament (calcium hydroxide paste) and sealed with a dry cotton pellet and a temporary filling.

33. Recurrent periapical abscess:
It is a condition where a tooth with an acute periapical abscess is relieved by emergency treatment after which the acute symptoms return. In some cases, the abscess may recur more than once, due to microorganism of high virulence or it results in resistance.
Management: The management and treatment are the same as for phoenix abscess

34. 5- Flare-ups Related to Necrotic Pulp
Teeth with necrotic pulp often develop as acute apical abscess after the initial appointment. As the lesion, is confined to bone, there occurs severe pain.
Management: The drainage is established, canal copiously
irrigated, and the tooth sealed after placing an intracanal
medicament of calcium hydroxide. Increasing the
appointment time allows more exposure of the bacteria to
irrigants like hydrogen peroxide and sodium hypochlorite,
thus reducing the chances of flare-ups.

35. 2- Postobturation Flare-ups
Only 1/3 of the endodontic patients experience some pain after obturation . A mild pain is usually present which may resolve spontaneously. Patients experiencing preoperative pain are more likely to suffer from postobturation flare-ups. Another cause of postobturation flare-ups may be over-extended root canal fillings.
Management: Mild to moderate pain may be controlled
with analgesics. For cases with severe pain, retreatment is
indicated.

36. Management of flare-ups
A -Preventive Management
• Proper diagnosis.
• Long acting local anesthesia.
• Determination of proper working length.
• Complete debridement.
• Occlusal reduction.
• Placement of intracanal medicament in case of multi-visit root
canal treatment.
• Medications.
• Closed dressing.
• Behavioral management.

37. 1- Proper Diagnosis
Before initiating endodontic therapy, proper diagnosis of the condition should be made so as to prevent incorrect treatment that may lead to pain, swelling or both to the patient.
2- Long Acting Local Anesthetics
Long acting anesthetics, e.g. bupivacaine, provide increased period of analgesia for up to 8-10 hours during the immediate postoperative period.
3- Determination of the Proper Working Length
Inaccurate measurement of WL may lead to under or overinstrumentation and extrusion of debris, irrigants, medicaments or filling materials beyond the apex.

38. 4- Complete Debridement
Thorough cleaning and shaping of the root canal system may decrease the incidence of flare-ups. Maintenance of apical patency and crown-down preparation technique are two important factors in the management of flare-ups
5- Occlusal Reduction
It is a valuable pain preventive strategy in appropriate cases.
The relief of pain provided by occlusal reduction is due
to the reduction of mechanical stimulation of sensitized
nociceptors.

39. 6- Placement of Intracanal Medicament in Multi-visit RCT
Calcium hydroxide serves the following purposes:
• Antimicrobial action:. The antimicrobial effect of calcium hydroxide
remains in the canal for one week.
• It obliterates the root canal space which minimizes the ingress of tissue exudates, a potential source of nourishment of remaining bacteria.
• Extrusion of calcium hydroxide periapically reduces inflammatory reaction by reducing substrate adherence capacity of macrophages.
• Calcium hydroxide has soft tissue dissolving property because of its high pH. Its denaturing effect on the necrotic tissue, allows sodium hypochlorite to dissolve remaining tissue more easily.

40. 7- Medications
• Systemic antibiotics:. Antibiotics should be recommended only in cases of medically compromised patients at high risk levels and in cases of spreading infection that indicates failure of local host responses to control bacterial irritants.
The commonly prescribed antibiotics include penicillin, erythromycin or cephalosporin. Metronidazole, tinidazole, ornidazole and clindamycin are also used because of their efficacy against anaerobic bacteria.
• Analgesics: (NSAIDs)and acetaminophen are the most commonly used drugs to reduce pain. Treatment with an NSAID before a procedure
has shown to reduce postoperative pain. Most commonly used drugs include ibuprofen, diclofenac sodium and ketorolac.

41. 9- Behavioral Management
8- Closed Dressing
Leaving a tooth open for drainage is contraindicated as it can cause contaminations from the oral cavity and lead to flareups.
Drainage should be allowed under the rubber dam, and
the tooth closed immediately after the treatment to prevent
secondary infections.
9- Behavioral Management
Providing information about the procedure in an important
step in reducing patient anxiety

42. B- Management of flare-ups
• Drainage through coronal access opening.
• Incision and drainage.
• Proper instrumentation.
• Trephination.
• Intracanal medicaments.
• Analgesics and antibiotics (when indicated

43. B- Definitive Treatment
1- Drainage through the Coronal Access Opening
The first step in relieving the pain is to establish drainage through the root canal, when it has not been obturated or poorly obturated. Sometimes apical trephination may be needed to establish drainage.
2- Incision and Drainage
Occasionally more than one abscess is present in relation to the tooth. One communicates with the apex, while other is present in the vestibule. As they do not communicate with one another, flare-up can be best managed through a combination of canal instrumentation and incision and drainage

44. 3- Proper Instrumentation
Under profound local anesthesia, working length should be re-established, apical patency obtained and thorough chemomechanical preparation is done.
4- Trephination
When drainage through the canal is not possible, surgical trephination can be used as a palliative measure. However, it is not the first line of treatment because of the additional trauma, invasiveness and questionable beneficial result.

45. 5- Intracanal Medicaments
Use of corticosteroid-antibiotic combination as an intracanal medicament has been recommended to reduce pain, especially in cases of over instrumentation.
6- Analgesics and Antibiotics
For most of the patients, NSAIDs are sufficient to control pain. However, if the pain cannot be controlled with NSAIDs, opoid analgesics can be used to supplement with NSAIDs.
Antibiotics are prescribed for the treatment of flare-ups only when indicated as discussed before. Use of antihistaminics for treatment of flare-ups has also been suggested.

46. CONCLUSION
The development of flare-up after the endodontic treatment appointment is an extremely undesirable problem.
Despite judicious and careful treatment procedures, severe pain, swelling or both may occur.
The clinician should employ proper measures and follow appropriate guidelines

47. Thanks alot

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